Deck 29: Communication and Physical Assessment of the Child and Family

Question 1

With the National Center for Health Statistics (NCHS)criteria,which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

A) 10th percentile
B) 9th percentile
C) 85th percentile
D) 95th percentile

Answer 1

85th percentile

Question 2

The nurse is interviewing the mother of an infant.She reports,"I had a difficult delivery,and my baby was born prematurely." This information should be recorded under which heading?

A) Birth history
B) Present illness
C) Chief complaint
D) Review of systems

Answer 2

Birth history

Question 3

An 8-year-old girl asks the nurse how the blood pressure apparatus works.The most appropriate nursing action is to:

A) ask her why she wants to know.
B) determine why she is so anxious.
C) explain in simple terms how it works.
D) tell her she will see how it works as it is used.

Answer 3

explain in simple terms how it works.

Question 4

Where in the health history should the nurse describe all details related to the chief complaint?

A) Past history
B) Chief complaint
C) Present illness
D) Review of systems

Question 5

When the nurse interviews an adolescent,it is especially important to:

A) focus the discussion on the peer group.
B) allow an opportunity to express feelings.
C) emphasize that confidentiality will always be maintained.
D) use the same type of language as the adolescent.

Question 6

Which parameter correlates best with measurements of the body's total protein stores?

A) Height
B) Weight
C) Skin-fold thickness
D) Upper arm circumference

Question 7

The nurse is taking a sexual history on an adolescent girl.The best way to determine whether she is sexually active is to:

A) ask her, "Are you sexually active?"
B) ask her, "Are you having sex with anyone?"
C) ask her, "Are you having sex with a boyfriend?"
D) ask both the girl and her parent if she is sexually active.

Question 8

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones such as the age of walking without assistance.This should be considered because these milestones are:

A) unnecessary information because the child is age 3 years.
B) an important part of the family history.
C) an important part of the child's past growth and development.
D) an important part of the child's review of systems.

Question 9

Which age-group is most concerned with body integrity?

A) Toddler
B) Preschooler
C) School-age child
D) Adolescent

Question 10

When doing a nutritional assessment on an Hispanic family,the nurse learns that their diet consists mainly of vegetables,legumes,and starches.The nurse should recognize that this diet:

A) indicates that they live in poverty.
B) is lacking in protein.
C) may provide sufficient amino acids.
D) should be enriched with meat and milk.

Question 11

An appropriate approach to performing a physical assessment on a toddler is to:

A) always proceed in a head-to-toe direction.
B) perform traumatic procedures first.
C) use minimal physical contact initially.
D) demonstrate use of equipment.

Question 12

The nurse is seeing an adolescent boy and his parents in the clinic for the first time.What should the nurse do first?

A) Introduce himself or herself.
B) Make the family comfortable.
C) Explain the purpose of the interview.
D) Give an assurance of privacy.

Question 13

The earliest age at which a satisfactory radial pulse can be taken in children is:

A) 1 year.
B) 2 years.
C) 3 years.
D) 6 years.

Question 14

What is the single most important factor to consider when communicating with children?

A) The child's physical condition
B) The presence or absence of the child's parent
C) The child's developmental level
D) The child's nonverbal behaviors

Question 15

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

A) Face
B) Buttocks
C) Oral mucosa
D) Palms and soles

Question 16

By what age do the head and chest circumferences generally become equal?

A) 1 month
B) 6 to 9 months
C) 1 to 2 years
D) 2.5 to 3 years

Question 17

The nurse is taking a health history on an adolescent.Which best describes how the chief complaint should be determined?

A) Ask for a detailed listing of symptoms.
B) Ask the adolescent, "Why did you come here today?"
C) Use what the adolescent says to determine, in correct medical terminology, what the problem is.
D) Interview the parent away from the adolescent to determine the chief complaint.

Question 18

Which action is most likely to encourage parents to talk about their feelings related to their child's illness?

A) Be sympathetic.
B) Use direct questions.
C) Use open-ended questions.
D) Avoid periods of silence.

Question 19

Which tool measures body fat most accurately?

A) Stadiometer
B) Calipers
C) Cloth tape measure
D) Paper or metal tape measure

Question 20

What is an important consideration for the nurse who is communicating with a very young child?

A) Speak loudly, clearly, and directly.
B) Use transition objects such as a doll.
C) Disguise own feelings, attitudes, and anxiety.
D) Initiate contact with the child when the parent is not present.

Question 21

The nurse should expect the anterior fontanel to close at age:

A) 2 months.
B) 2 to 4 months.
C) 6 to 8 months.
D) 12 to 18 months.

Question 22

Which data would be included in a health history? (Select all that apply.)

A) Review of systems
B) Physical assessment
C) Sexual history
D) Growth measurements
E) Nutritional assessment
F) Family medical history

Question 23

The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes.The rationale for this position is that:

A) it prevents cremasteric reflex.
B) undescended testes can be palpated.
C) this tests the child for an inguinal hernia.
D) the child does not yet have a need for privacy.

Question 24

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change.The nurse decides to do a simple magic trick using gauze.This should be interpreted as:

A) inappropriate, because of child's age.
B) a way to establish rapport.
C) too distracting, when cooperation is important.
D) acceptable, if there is adequate time.

Question 25

The appropriate placement of a tongue blade for assessment of the mouth and throat is the:

A) the center back area of the tongue.
B) the side of the tongue.
C) against the soft palate.
D) on the lower jaw.

Question 26

During examination of a toddler's extremities,the nurse notes that the child is bowlegged.The nurse should recognize that this finding is:

A) abnormal and requires further investigation.
B) abnormal unless it occurs in conjunction with knock-knee.
C) normal if the condition is unilateral or asymmetric.
D) normal because the lower back and leg muscles are not yet well developed.

Question 27

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup.Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply)

A) The cuff is labeled "toddler."
B) The cuff bladder width is approximately 40% of the circumference of the upper arm.
C) The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
D) The cuff bladder covers 50% to 66% of the length of the upper arm.

Question 28

The nurse must assess a child's capillary refilling time.This can be accomplished by:

A) inspecting the chest.
B) auscultating the heart.
C) palpating the apical pulse.
D) palpating the skin to produce a slight blanching.

Question 29

Which term is used to describe breath sounds that are produced as air passes through narrowed passageways?

A) Rubs
B) Rattles
C) Wheezes
D) Crackles

Question 30

When palpating the child's cervical lymph nodes,the nurse notes that they are tender,enlarged,and warm.The best explanation for this is:

A) some form of cancer.
B) local scalp infection common in children.
C) infection or inflammation distal to the site.
D) infection or inflammation close to the site.

Question 31

During a routine health assessment,the nurse notes that an 8-month-old infant has significant head lag.Which is the nurse's most appropriate action?

A) Teach the parents appropriate exercises.
B) Recheck head control at the next visit.
C) Refer the child for further evaluation.
D) Refer the child for further evaluation if the anterior fontanel is still open.

Question 32

During a funduscopic examination of a school-age child,the nurse notes a brilliant,uniform red reflex in both eyes.The nurse should recognize that this is:

A) a normal finding.
B) an abnormal finding; the child needs referral to an ophthalmologist.
C) a sign of a possible visual defect; the child needs vision screening.
D) a sign of small hemorrhages, which usually resolve spontaneously.

Question 33

What type of breath sound is normally heard over the entire surface of the lungs,except for the upper intrascapular area and the area beneath the manubrium?

A) Vesicular
B) Bronchial
C) Adventitious
D) Bronchovesicular

Question 34

The nurse is testing an infant's visual acuity.By what age should the infant be able to fix on and follow a target?

A) 1 month
B) 1 to 2 months
C) 3 to 4 months
D) 6 months

Question 35

Kimberly is having a checkup before starting kindergarten.The nurse asks her to do the "finger-to-nose" test.The nurse is testing for:

A) deep tendon reflexes.
B) cerebellar function.
C) sensory discrimination.
D) ability to follow directions.

Question 36

The most frequently used test for measuring visual acuity is the:

A) Denver Eye Screening test.
B) Allen picture card test.
C) Ishihara vision test.
D) Snellen letter chart.

Question 37

Binocularity,the ability to fixate on one visual field with both eyes simultaneously,is normally present by what age?

A) 1 month
B) 3 to 4 months
C) 6 to 8 months
D) 12 months

Question 38

A school nurse is screening children for scoliosis.Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply.)

A) Complaints of a sore back
B) Asymmetry of the shoulders
C) An uneven hemline
D) Inability to bend at the waist
E) Unequal waist angles

Question 39

The nurse has just started assessing a young child who is febrile and appears very ill.There is hyperextension of the child's head (opisthotonos)with pain on flexion.The most appropriate action is to:

A) refer for immediate medical evaluation.
B) continue the assessment to determine the cause of neck pain.
C) ask the parent when the child's neck was injured.
D) record "head lag" on the assessment record and continue the assessment of the child.

Question 40

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

A) S₁, S₂
B) S₃, S₄
C) Murmur
D) Physiologic splitting

Question 41

MATCHING
Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

Step 2

A)Auscultation
B)Palpation
C)Inspection
D)Percussion

Question 42

MATCHING
Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

Step 1

A)Auscultation
B)Palpation
C)Inspection
D)Percussion

Question 43

MATCHING
Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

Step 4

A)Auscultation
B)Palpation
C)Inspection
D)Percussion

Question 44

MATCHING
Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

Step 3

A)Auscultation
B)Palpation
C)Inspection
D)Percussion

Question 45

A nurse is performing an assessment on a school-age child.Which findings suggest the child is receiving an excess of vitamin A? (Select all that apply.)

A) Delayed sexual development
B) Edema
C) Pruritus
D) Jaundice
E) Paresthesia

Question 46

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family.Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)

A) Elicit one answer at a time.
B) Interrupt the interpreter if the response from the family is lengthy.
C) Comments to the interpreter about the family should be made in English.
D) Arrange for the family to speak with the same interpreter, if possible.
E) Introduce the interpreter to the family.